Description
About Us:
Revive is a dynamic and innovative organization specializing in healthcare delivery and technology. We pride ourselves on delivering exceptional products/services and building strong, long-lasting relationships with our valued clients.
Position Description:
The Manager of Eligibility and Implementation Services is responsible for overseeing eligibility across the enterprise to ensure accurate, timely, and compliant determination of member eligibility. They will also supervise implementations of new groups, coordinating with Customer Success to ensure timely group creation. This role leads a team, optimizes processes, collaborates cross-functionally, and ensures high service quality while meeting organizational standards.
Duties:
Eligibility Leadership
- Oversee the end-to-end eligibility processes, including data collection, validation, and transmission from customers to downstream systems and vendors.
- Manage day-to-day eligibility services, including verification, enrollment, maintenance, and termination processes.
- Review, reconcile, and audit eligibility files for accuracy, completeness, and compliance with contract provisions.
- Ensure accuracy and timeliness of eligibility determinations in accordance with policies and contracts.
- Identify and resolve complex eligibility discrepancies, ensuring prompt resolution and minimal impact on member coverage.
- Develop, document, and improve workflows to enhance efficiency and reduce errors.
Implementation Oversight
- Supervise end-to-end group onboarding and implementation for new clients, ensuring smooth setup, coordination between departments, configuration, and launch within agreed timelines.
- Act as primary escalation point for complex implementation issues, removing blockers, and driving resolution across teams.
- Partner cross-functionally with Customer Success to ensure accurate handoffs and go-lives.
- Support strategic implementation planning for large or complex groups, including renewals, product changes, and open enrollment.
People Management
- Lead, coach, and develop eligibility and implementation team members.
- Conduct performance reviews, provide ongoing feedback, and support professional growth.
- Ensure appropriate staffing levels and training to meet service demands.
Quality & Compliance
- Monitor quality metrics, audits, and error rates; implement corrective action plans as needed.
- Ensure compliance with applicable regulations (e.g., HIPAA).
- Partner with Compliance and Legal teams to address regulatory updates and risks.
Cross-Functional Collaboration
- Work closely with IT, Finance, and Customer Success and external partners (e.g., Customers, Vendors, etc).
- Serve as a subject matter expert for eligibility-related issues and escalations.
- Support system implementations, upgrades, and data integrity initiatives.
- Provide expert guidance and training to junior analysts and eligibility team members.
- Support customer onboarding and renewal processes by validating eligibility requirements and system configurations.
Reporting, Data Analysis & Continuous Improvement
- Track and report key performance indicators (KPIs) such as turnaround time, accuracy, and backlog.
- Analyze trends and identify opportunities for automation and process optimization.
- Lead or support continuous improvement initiatives.
- Conduct detailed analysis of eligibility data to identify trends, errors, and process gaps.
- Develop and maintain standard and ad hoc reports related to eligibility metrics and data integrity.
- Utilize Excel, SQL, or BI tools to perform quality assurance and reporting for internal stakeholders.
- Lead or participate in system testing and data validation for upgrades and new implementations.
- Create and maintain detailed documentation of eligibility workflows, data mapping, and standard operating procedures (SOPs).
Requirements
- Bachelor’s degree or equivalent work experience.
- 8+ years of experience in eligibility, enrollment, implementation or benefits administration within healthcare, insurance, or a related industry.
- 5+ years of people management or team leadership experience
- Strong knowledge of eligibility processes, data management and implementation
- Excellent communication, problem-solving, and organizational skills
- Strong analytical and problem-solving skills with advanced Excel proficiency (pivot tables, VLOOKUP, data validation).
- Experience with eligibility file formats (EDI 834, XML, CSV) and data exchange protocols.
Preferred:
- Proficiency with basic SQL to query and analyze eligibility data, identify discrepancies, and support troubleshooting efforts.
